Provider First Line Business Practice Location Address:
1419 S BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19147-4919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-462-3191
Provider Business Practice Location Address Fax Number:
215-755-6383
Provider Enumeration Date:
09/18/2009